QUESTION: 173

A56-year-old Black male construction worker comes for evaluation of a worsening, nonproductive cough that he first noticed 2 months before. During the last week the cough has worsened and has become productive of yellow, blood-tinged sputum. He reports his appetite is poor, and he has lost approximately 15 lbs over the past 2 months. You take a social history and find out he has smoked two packs of cigarettes a day since he was 16 years old. He states that he drinks approximately 10 beers per week. You perform a physical examination. He appears chronically ill; however, his vital signs are normal. The head and neck examination is within normal limits. There are decreased breath sounds in the left upper chest. Breath sounds are distant in the other lung fields. The diaphragms are low. There is no palpable hepatosplenomegaly. You order a posterior-to-anterior (PA) and lateral CXR. The chest radiogram shows opacity of the left upper lobe. There are no pleural effusions. The cardiac silhouette is not enlarged. The mediastinum does not appear enlarged. What next should be ordered?

Culture sputum, blood, and urine; administer a broad-spectrum antibiotic; order apical lordotic x-ray views.
Culture sputum, blood, and urine; order a spiral CT scan of the chest.
Culture sputum, blood, and urine; order an MRI of the chest.
Treat with broad-spectrum antibiotics for pneumonia, and tell him to come back in3 months to repeat the chest radiography.
Culture sputum, blood, and urine; order a positron emission tomographic (PET) scan.

Answer(s): B

Explanation:

Because there is a smoking history, it is appropriate to order a spiral CT scan to better delineate whether the mass is a tumor, an infectious process, or both. Tumor blocking a bronchus can frequently be associated with a pneumonia involving lung behind the compressed bronchus; therefore, the evaluation should include collecting the appropriate cultures along with the further imaging. The full staging of small cell lung cancer is very important both for prognosis to relate to the patient and his family and to define the most appropriate therapy. Therefore, it is appropriate to order the MRI studies of the head along with CT scans with contrast of the abdomen and pelvis, a bone scan and a bone marrow aspirate and biopsy to determine if the disease is limited to the thorax or has metastasized to other organs. Small cell lung cancer limited to the thorax is potentially a disease that can achieve complete, long-term remissions with appropriate therapy. Small cell lung cancer metastatic beyond the chest can be well palliated but, at this time, our current treatments are unable to induce a long-term disease-free remission. Surgery alone is not an appropriate treatment for small cell lung cancer. Even with a successful complete tumor resection, without systemic therapy (chemotherapy), the small cell lung cancer recurs in 100% of cases within months to several years.

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QUESTION: 174

A56-year-old Black male construction worker comes for evaluation of a worsening, nonproductive cough that he first noticed 2 months before. During the last week the cough has worsened and has become productive of yellow, blood-tinged sputum. He reports his appetite is poor, and he has lost approximately 15 lbs over the past 2 months. You take a social history and find out he has smoked two packs of cigarettes a day since he was 16 years old. He states that he drinks approximately 10 beers per week. You perform a physical examination. He appears chronically ill; however, his vital signs are normal. The head and neck examination is within normal limits. There are decreased breath sounds in the left upper chest. Breath sounds are distant in the other lung fields. The diaphragms are low. There is no palpable hepatosplenomegaly. You order a posterior-to-anterior (PA) and lateral CXR. The chest radiogram shows opacity of the left upper lobe. There are no pleural effusions. The cardiac silhouette is not enlarged. The mediastinum does not appear enlarged.

The patient has the follow-up test that you recommend. It shows a 5-cm mass compressing the left upper lobe bronchus with consolidation of the left upper lobe. Two 1 cm peribronchial lymph nodes near the left main stem bronchus and several 1.52.0 cm mediastinal lymph nodes are seen. The hilar nodes do not appear enlarged. There are no enlarged lymph nodes visualized in the right chest. There are no lesions seen in the right lung. There are emphysematous changes involving both lungs.

A biopsy of the lung mass shows a small cell carcinoma. What should be done next?

MRI of the brain with and without gadolinium contrast
complete pulmonary function studies followed by a left pneumonectomy
left upper lobectomy
radiation of the left upper lobe mass and the mediastinal lymph nodes
chemotherapy

Answer(s): A

Explanation:

Because there is a smoking history, it is appropriate to order a spiral CT scan to better delineate whether the mass is a tumor, an infectious process, or both. Tumor blocking a bronchus can frequently be associated with a pneumonia involving lung behind the compressed bronchus; therefore, the evaluation should include collecting the appropriate cultures along with the further imaging. The full staging of small cell lung cancer is very important both for prognosis to relate to the patient and his family and to define the most appropriate therapy. Therefore, it is appropriate to order the MRI studies of the head along with CT scans with contrast of the abdomen and pelvis, a bone scan and a bone marrow aspirate and biopsy to determine if the disease is limited to the thorax or has metastasized to other organs. Small cell lung cancer limited to the thorax is potentially a disease that can achieve complete, long-term remissions with appropriate therapy. Small cell lung cancer metastatic beyond the chest can be well palliated but, at this time, our current treatments are unable to induce a long-term disease-free remission. Surgery alone is not an appropriate treatment for small cell lung cancer. Even with a successful complete tumor resection, without systemic therapy (chemotherapy), the small cell lung cancer recurs in 100% of cases within months to several years.

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QUESTION: 175

A 45-year-old female develops fever, dysuria, and back pain and is admitted to the hospital after evaluation in the ER discloses pyelonephritis. The patient is placed on broad-spectrum antibiotics and has a good improvement in her symptoms. On hospital day 4, the patient develops a new fever, leukocytosis, and profuse watery diarrhea. A colonoscopy is performed and the following finding is seen

What is the first-line therapy for treating this disorder?

metronidazole
vancomycin
oral corticosteroids
rectal administration of topical corticosteroids
sulfasalazine

Answer(s): A

Explanation:

The colonoscopy image demonstrates the pseudomembranes classically seen in pseudomembranous colitis, also known as Clostridium difficile colitis. C. difficile colitis is commonly encountered in patients on broadspectrum antibiotics, although almost any antibiotic can predispose a patient to this illness. The disease is toxin mediated, and is frequently seen when antibiotics disrupt the normal balance of gut flora, allowing C. difficile to more widely colonize the bowel than it would normally. Crohn colitis and ulcerative colitis would have different patterns of ulceration of the mucosa, which is not seen here. Ischemic colitis would appear as an area or areas of blanched, edematous, or frankly necrotic mucosa due to an interruption of vascular flow. Microscopic colitis, which can cause a chronic form of watery diarrhea, typically has a normal appearance at colonoscopy. The first-line therapy for patients diagnosed with pseudomembranous colitis is typically a course of oral metronidazole. Patients can also receive oral vancomycin, although this is usually reserved for persistent or recurrent infection. Oral vancomycin also carries a much higher cost than metronidazole. Oral or topical= steroids would be contraindicated in the setting of an infection, although these medications are frequently used in patients with IBD such as ulcerative colitis or Crohn colitis. Sulfasalazineis a topical anti-inflammatory agent that is also sed for patients with IBD.

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QUESTION: 176

A45-year-old male presents to the hospital for acute abdominal pain and is found to have acute pancreatitis. He has no past medical history but recently has noticed urinary frequency and muscle weakness. He takes no medications. He denies alcohol use. His liver function tests during the episode are normal and magnetic resonance cholangiopancreatography study (MRCP) demonstrates an absence of stones in the biliary tree as well as a normal pancreatic duct. His serum calcium is found to be markedly elevated during this episode. The patient recovers clinically, and repeat serum calcium is also found to be elevated 1 month after hospital discharge.

What is the most likely cause of his hypercalcemia?

metastatic bone disease
sarcoidosis
vitamin D overdose
hyperparathyroidism
laboratory error

Answer(s): D

Explanation:

The patient likely has hyperparathyroidism. Hyperparathyroidism can lead to chronic hypercalcemia, a known cause of acute pancreatitis. Aserum calcium level can be elevated in many patients during acute pancreatitis due to dehydration and should be checked after the event has resolved. Hyperparathyroidism would also explain his urinary frequency and muscle weakness. Laboratory error is unlikely given that the level is elevated on two occasions. Metastatic bone disease and sarcoidosis can also cause hypercalcemia but hyperparathyroidism is more commonly associated with pancreatitis. Vitamin D overdose is unlikely given his lack of medication use.

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